Aim. To audit the community psychiatric services in southern Gauteng with a view to determining whether the objectives of the country's mental health legislation and policies are being achieved.

Results. Although southern Gauteng's community psychiatric clinics are situated in a primary health setting, primary health clinicians play no active role in the management of mentally ill patients. Care is supplied mainly by specialist psychiatrists, psychiatric registrars (in training) and psychiatric nurses. For first appointments, a mean of 2 patients are seen per doctor per clinic day for a mean duration of 30 minutes. For follow-up appointments, a mean of 17 patients are seen per doctor per clinic day for a mean duration of 8 minutes. The waiting time for new patient appointments is a mean of 6 months. Follow-up patients are seen once a month by nursing staff and approximately once every 4 months by doctors. An average of 1 in 5 patients is treated with oral atypical antipsychotics; in the majority of clinics, this is the total extent of care. However, where psychologists, social workers and occupational therapists are present, only 0.2% of all users have access to them.
Conclusion. The community psychiatric services, although better than those in some other countries, fall short of what is required by South African legislation and policies. General community health services ought to play an active role in the structure and delivery of psychiatric services by developing and strengthening the current limited services, with an emphasis on cost-effective and preventive approaches. Existing community psychiatric services, if so transformed, could serve as a model for other countries in Africa.

Topiramate enhances gamma-amino-butyric acid effects, has antiglutaminergic effects, and is a state-dependent sodium channel blocker. It is registered as an adjunctive treatment for epilepsy but is not registered for psychiatric indications. Nevertheless, it may be useful beyond its initial indication, considering the promising literature on which I report below. However, much more research evidence is needed to establish sufficient scientific justification for prescribing it routinely for psychiatric purposes.

Aim. Early identification and prevention of relapse in patients with schizophrenia has significant therapeutic and socio-economic implications. The aim of this study was to determine the factors, if any, that may be associated with relapse in a group of patients in Johannesburg.

Method. Patients were recruited from mental health outpatient clinics in a predominantly residential area during the period January 1995-June 2005. They were included if a review of their records confirmed a diagnosis of schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV); they had no other psychotic illness; and they were ≥ 18 years old. Patients were excluded if the diagnosis of schizophrenia had first been made in the preceding 6 months. Demographic and clinical characteristics of the patients were obtained from their case notes.
Results. Of the 217 patients who were included in the study, 61.8% (N = 134) had a history of at least 1 relapse. There was no significant difference (p > 0.05) between those who relapsed and those who did not relapse in terms of gender, marital status or employment status. Approximately 46% (N = 61) of those who relapsed had co-morbid psychiatric disorders, compared with 10.8% (N = 9) in those who did not relapse (p < 0.0001), but there was no significant difference between the two groups when comparing the presence of co-morbid medical disorder (p = 0.348). Nearly half (N = 63) of patients who relapsed had a history of substance abuse (p = 0.0054); cannabis was significantly more abused (p = 0.0014). Two-thirds (N = 138) of the study population did not adhere to their treatment, of whom 80.4% (N = 107) experienced a relapse (p < 0.0001). Significant multiple logistic regression models for patients who relapsed included poor adherence due to side-effects (odds ratio (OR) = 3.032; p = 0.023; 95% confidence interval (CI) 1.168 - 7.870); poor adherence due to lack of insight (OR = 5.29; p < 0.0001; 95% CI 2.28 - 12.20), and co-morbid depressed mood (OR = 5.33; p < 0.001; 95% CI 2.32 - 12.22).
Conclusion. Co-morbid depressed mood, poor adherence owing to lack of insight, and medication side-effects were the factors most likely to increase the risk of relapse in patients with schizophrenia. Risk of relapse may be reduced when the treating psychiatrist identifies and addresses these factors.

Orexin-A and Orexin-B (also known as hypocretin 1 and 2) are, respectively, 33- and 28-amino acid residue peptides that activate a G-protein-coupled 'orphan' receptor, i.e. which has no known ligand. Immuno-cytochemical studies show that orexin-positive neurons are located in the lateral hypothalamic area and arcuate and perifornical nuclei.